Health insurance for prostheses

Health insurance for prostheses: how Australian health funds cover you

Fund	Prostheses conditions	More info
	Except for excluded services, ahm will cover you up to the minimum benefit listed on the Government's Prostheses List.	More info
	Government approved, non-cosmetic prostheses that have been surgically implanted are covered by your HCF hospital product.	Get quote
	Government approved prosthetic devices.	Get quote
	Government approved prosthetic devices.	More info
	Government approved prosthetic devices.	Get quote
	Australian Unity will cover the minimum cost for government approved surgically implanted items. Non-admitted prosthesis requests are subject to prior application and approval.	More info
	If you're planning on claiming for appliances, blood glucose monitor, extremity pump, GMHBA approved orthopaedic appliances, nebuliser pump,non surgical prostheses, pressure garments, sleep apnoea monitor or tens monitor, you'll require a doctor's letter of recommendation.	Get quote
	Government approved, non-cosmetic prostheses that have been surgically implanted are covered by the fund.

What are prostheses?

Prostheses is the plural form of prosthesis, or an artificial body part. Examples include anything from an artificial leg to an artificial heart to metal screws and plates that reinforce the skeleton.

How are prostheses covered by Medicare?

If your prosthesis is part of a Medicare-approved treatment, the device is included in your Medicare cover automatically. For example, if you're getting a hip replacement, the cost of the artificial hip is covered in addition to the surgery itself.

Prostheses are generally funded in the following ways:

• Your state's public health system. Many states cover artificial limbs as long a doctor refers you, you're a resident of the state and you have a valid Medicare card.
• Department of Veteran Affairs. If you lost your limb while serving or you have a Gold Card, you will be eligible for cover through the Department of Veteran Affairs.
• The National Disability Insurance Scheme (NDIS). Many amputations are due to medical conditions like diabetes. If that's the case, you may be eligible for prostheses through the NDIS.

You won't be covered for prostheses if it's for cosmetic purposes only. For example, the public system won't cover breast implants unless it's to reconstruct your breasts after a mastectomy.

Does private health insurance cover prostheses?

Yes. Just like Medicare, your private hospital insurance will cover the cost of your prosthesis as long as it forms part of a treatment listed on your policy and is considered medically necessary.

There are a few benefits to using private cover for prostheses:

• You skip the waiting lists. If your treatment isn't urgent, Medicare will make you wait for your treatment. Private insurance can let you skip the queue so you can get the treatment you need sooner. If you need a shoulder replacement and are in constant pain, you probably don't want to wait too long to get it fixed.
• You get to choose your doctor. With Medicare, you have to use who they tell you to use. Private insurance lets you choose the doctor you're most comfortable with.
• You can get extra physio. Medicare will cover in-hospital physio but often won't cover outpatient treatment. Some extras policies will cover outpatient physio, which is important if you need to regain your range of motion following an implant.

What is the Prostheses List?

The Prostheses List is the Australian government's official list of more than 11,000 surgically implanted prostheses and other devices required for the implants to function.

It's basically a list of vetted products, down to the brand and model number in some cases. If your private health insurance covers a particular treatment requiring prostheses, your private doctor must use a device on this list and your insurer must reimburse you the minimum benefit amount, which is also included in this official list.

The government updates the list three times a year to keep up with the never-ending improvements in medical technology. Having a regularly updated list of properly vetted devices helps keep insurance costs down since it reduces the chance of follow-up surgery due to malfunction.

What items are on the Prostheses List?

Items on the Prostheses List are broken up into several categories:

The latest version of the Prostheses List is available from the Department of Health website.

How to find health insurance for prostheses

With health insurance, you'll be covered for prostheses based on the type of treatment rather than whether or not a prosthesis is involved. For example, if your policy covers heart surgery but not hip replacements, you'll be covered for a pacemaker but not an artificial hip.

Health insurance can be broken into 4 tiers: Gold, Silver, Bronze and Basic. The level you choose will determine what treatments you are covered for and therefore what prostheses are covered.

Here are examples of some treatments you'll find at each level and an example of a prosthesis that's included:

• Basic. Insurers are allowed, but not required, to offer you restricted cover that will pay for the prosthetic device but not for the surgery to implant it. However, in most cases, there will be no cover for any treatments that would require a prosthesis.
• Bronze. Offers bone, joint and muscle cover (bone screws) and medically necessary breast surgery (reconstructive breast implants following mastectomy).
• Silver. Offers all of the above plus heart and vascular system cover (pacemaker); back, spine and neck cover (vertebrae replacement) and hearing implant cover (middle ear implant)
• Gold. All of the above plus joint replacement cover (artificial hip) and insulin pump cover (insulin pump cover is separate from diabetes cover).

What is a no-gap prosthesis?

Most devices on the Prostheses List are considered no-gap prostheses, meaning your insurer has to cover the full cost of the device. There are some gap-permitted prostheses you can be charged for, but for every gap-permitted device, there is an equivalent no-gap device also on the list. Feel free to ask your doctor to use the no-gap version if you are concerned about cost.

The gap-permitted items on the list will have an amount listed in the maximum benefits column in addition to the minimum benefits column. If the maximum benefits column is blank, it is a no-gap prosthesis and you won't be charged any extra for it.

Are there out-of-pocket expenses for prostheses?

With private health insurance, you usually won't pay out-of-pocket for the device itself but you may see some out-of-pocket charges related to the surgery.

When you use private health insurance in a private hospital, Medicare and your insurer team up to pay the Medicare Schedule Fee for that treatment (ie, what Medicare alone would have paid had you gone public).

But private doctors are free to set their own prices leaving you responsible for any difference. This is called your gap. The good news is you can avoid some or even all of this gap if your insurer offers an Access Gap Cover scheme in which certain doctors agree to lower their prices for the fund's members.

What is the difference between a prosthesis and a health appliance?

The phrase health appliance is a catch-all term that includes artificial body parts like prostheses but also includes sensory aids like eyeglasses and medical devices such as blood pressure monitors. Unlike prostheses, these other appliances support rather than replace body parts.

Health Appliances = Prostheses + Sensory Aids + Medical Devices

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Frequently asked questions

• What are prostheses?

  Prostheses are artificial devices that are used to replace a missing body part, such as a limb or joint. They can be made from a variety of materials, including plastic, metal, and carbon fiber, and are custom-designed to fit the individual's specific needs and goals.

• How are prostheses fitted?

  Prostheses are fitted by a specialist prosthetist who works closely with the individual to design and create a device that meets their specific needs and goals. This process may involve taking measurements, making molds, and conducting trial fittings to ensure a proper fit and optimal function.

• Is private health insurance available for prostheses in Australia?

  Private health insurance policies in Australia can cover the cost of prostheses, including the initial fitting and any necessary adjustments or repairs, if it is required for treatment under a covered treatment category. For example, if you have coverage for heart conditions and your heart treatment requires prostheses, then it may be partially covered. However, the extent of coverage may vary depending on the policy and the individual's circumstances. It is important to check with your health insurer before the fitting to understand your coverage. The device will also need to be on the Australian prostheses list.

• What are the benefits of using a prosthesis?

  Prostheses can improve an individual's mobility, function, and quality of life by allowing them to perform daily activities that would otherwise be difficult or impossible. They can also help to restore a natural appearance and improve self-esteem. In addition, using a prosthesis can help to prevent the development of other medical conditions, such as joint contractures and muscle atrophy, which can occur as a result of a missing body part. Overall, prostheses can greatly improve an individual's independence, confidence, and quality of life.

Written by

Gary Ross Hunter

Journalist

Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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